Wednesday, November 10, 1045 Hours

When the human head smashes through a windshield, it’s not the multiple weave of lacerations criss-crossing the face that’s life threatening, it’s the damage you can’t see. The skull stops on impact but the brain continues its trajectory and slams into the bony interior, leaving a cascade of destroyed brain tissue in its wake. Blood vessels swell, slowing and eventually cutting off the flow of oxygen to the brain. Without oxygen, the brain dies. Survival depends on the extent of the damage and how fast the swelling can be reduced. If the brain hits the skull with enough force, sooner or later—usually later—death follows.

Another person without a seatbelt, I thought, watching two burly attendants position the gurney alongside the bed in intensive care and expertly lift the supine figure onto the bed. Soon an unbelieving family would arrive, stunned, numbed, unable to believe the patient in the bed was their husband, father, son.

I’d seen the same scenario too often in my more than twenty years in nursing, all of it at St. Teresa’s Hospital in South St. Louis. My recent job change, though, had me wondering if I had reached the limit of my abilities or, more likely, over-reached them. As part of our hospital’s reorganization, head nurses had become “clinical managers” and, instead of managing only one area (in my case it had been the intensive care unit), our responsibilities had been doubled to manage two units. The step-down unit, an intensive convalescent ward where critically-ill patients go to continue their recovery after leaving our unit, had been added to my already overworked schedule.

The man’s face had begun swelling above the cervical collar that stabilized his neck and around the oxygen cannula taped to his nose. Wanda, head nurse of the emergency room, squeezed by the gurney. Wanda had taken on managing the acute care clinic in addition to the emergency room in the recent shake-up.

“White male, approximately 30 to 35 years of age,” Wanda said, checking the patient’s fluids. Normal saline and lactated ringers solutions dripped into a wide-open IV taped to his arm, and a triple-lumen catheter placed in the left subclavian artery delivered blood, O-negative packed red cells, according to the label on the bag.

“Unrestrained driver, head-on into a tree, the cops said. And no air bag.” She checked the chart. “Unresponsive in acute respiratory distress and shock when we got him. See the obvious chest.” She pointed with the back end of her pen. “Retracts on inspiration and bulges on expiration.” The reverse of normal.

“Sternum and five right adjacent ribs have multiple fractures and you can see the air cast.” An inflated clear plastic tube temporarily stabilized his right arm, apparently fractured. “Mandible’s fractured too, that’s why the nasal intubation instead of an oral tube in his airway, although the nose might be broken as well,” she said as two nurses I hadn’t seen enter crowded around. Jessie and Tim, my most experienced RNs, followed behind them.

A train wreck, we called these cases.

“Alcohol?” I asked, noting the smell emanating from the patient.

“Blood alcohol .11 percent. Legally drunk. They’ve ordered sedation but watch for signs of withdrawal anyway.” Wanda glanced at the unconscious man in the bed. “He responds to verbal stimuli, but does not follow commands.” She moved to the head of the bed and pulled his eyelids up, flashing a penlight into one and then the other. “Pupils equally round, react sluggishly to light.”

Wanda handed me the chart. “He’s all yours.”

I passed off the chart to Jessie, who stayed to finish the patient’s initial assessment with help from the two newer nurses, and Tim and I followed Wanda out.

“What about your other one?” I asked Wanda. “Closed head. The one you called me about.”

“She’s in surgery. You’ll get her after that if. . . .” She shrugged.

“What happened to her?” Serena, a nursing student who worked for us part-time, asked. “Another car accident?”

“Hardly,” Wanda said, stuffing a pen and notes into the pockets of her rumpled green scrubs already stained with blood and other body fluids. “Somebody bashed the back of her head in. They’ve got a lot to do, get out the blood clot, skull fragments . . . it’ll be awhile till you get her. I’d guess another several hours.”

Jessie came out of our newly-admitted patient’s room and stopped Wanda who had turned to leave. “There’s no name on this chart. Who is he?” Jessie asked, her wandering eye giving her a deceptively distracted look.

“Sure there is,” Wanda said. “John Doe,” she added with a laugh as she hurried out the door.

“Check that bag of stuff they brought up with him,” I told Jessie. “They probably overlooked his ID in their rush downstairs. Or maybe security has it. Someone will know who he is.”
* * *

I was coming back from lunch when a balding, middle-aged man ambled off the elevator and followed me into ICU, which is what everyone in the hospital calls the intensive care unit.

“Detective McNamara,” he said, flipping open an ID badge as we reached the desk. An odor of stale cigar smoke lingered over him. “I’m here about the guy from the ER. They said you’ve got him up here.”

“We’ve got a lot of guys up here from the ER,” I said. “Who is it?”

“I don’t know his name. The officers were in pursuit when he smashed into a tree.”
A toothpick bounced up and down under a shaggy gray mustache as he talked.

“We’ve only got John Doe on the chart,” I told him.

“How about his effects?”

“His clothes and personal things?”

“My partner’s down in security looking for his personal effects but so far they couldn’t find them.” He swiped at his mustache with his thumb and forefinger. “Do you have anything of his up here?”

“I’ll check. You wait here,” I added when he started to follow me into the room. I was sure he had seen plenty of accident victims, but even that might not prepare him for how bad a patient looks hooked up to multiple lines, tubes, and monitors. A dummy, someone had said, describing a comatose patient, similar to the life-like mannequins used in nursing school labs to teach students before they use still-shaky skills on real live patients.

Jessie was finishing a neuro check on John Doe when I entered. Her black hands as sure as ever, she ran her unopened pen up his foot from heel to toe, getting no response from him. “Open your eyes,” Jessie said and the man made a guttural sound. “Can you squeeze my hand? Nothing,” she said to me. “They’re coming up to wire his jaw and set his arm. In the meantime, I’ll try to clean him up.” Large, the man’s weight appeared to be more muscle than fat, and his face and shaved head were suntanned, a tan line showing at his neck and upper arms. Fragments of glass, tree bark, and fibers clung to cuts on his face and scalp along with a coating of dried blood. Bloody mucous adhered to his nose and mouth.

At that moment the man’s arm flailed out, threatening to dislodge his IV, but instead it came to rest, dangling over the side of the bed, and he lay still again.

“You be careful,” I admonished. “I’ve been hit more than once.”

Although unconscious and unaware of what he was doing, his agitation could cause him to lash out, hitting whoever or whatever was nearby.

“He’s still jumpy because they want to hold up on sedation to get a read on his neuro status,” Jessie explained.

I picked up the clear plastic bag bundled with the man’s clothes from the bedside stand, and walked out. “John Doe’s personal effects,” I said to the detective who stroked his mustache with his thumb and forefinger watching me deposit the bag on the desk. All I could see through the clear plastic bag was a blood-splattered brown leather jacket.

“John Doe’s his name?” Serena asked me.

“That’s what we call someone when we don’t know their name—John Doe for a male, Jane Doe for a female,” I told her. “There must not have been any identification on him.”

“How could he be driving then?” she asked.

Our ward clerk, Ruby, snorted behind me. “You don’t know anyone who drives without a license? That’s probably why he was running from the cops,” she said, heading into the break room.

“He was?” Serena asked, mascara-laced eyes opened wide. “You mean he’s a criminal?”

“We don’t know that, Serena,” I said as the doors swung open and Mr. Hockstetter, the hospital’s chief operating officer, strode over to us, his eyes clamped on me.

“I just heard we’ve admitted a John Doe,” he said, ignoring the detective. “We can’t keep this up, Monika, taking care of every John Doe the cops bring here.”

“Redmond Hockstetter, meet Detective McNamara from the St. Louis City Police Department.”

Hockstetter had the grace to blush, but he quickly recovered. “Do you know who he is?” he asked. “We can’t subsidize these uninsured and still take care of the rest of you,” he added with a quick smile to McNamara.

“That’s what I’m here to find out,” McNamara said, reaching for the bag of John Doe’s property. “We’ll inventory it down in security. See if we can find out who he is.”

“Find out if the guy had insurance. Or any relatives,” Hockstetter said to McNamara. Then he turned around and headed back out. “Somebody’s got to pay for him,” he added just before the doors closed.

“How are you going to find out who he is?” Serena asked the detective, motioning toward John Doe’s room.

“Check with missing persons. See if anyone with his description fits the guy.” He handed me his card. “Let me know if he regains consciousness or you find out anything.” Then he was gone and we were left with our patients.

“What’d the cop want?” Ruby asked, placing her coffee cup on the U. S. Army coaster beside her phone.

“How’d you know he was a cop?” I asked. A ward clerk since before my time at St. Teresa’s, Ruby knew everything that went on in the hospital and now I’d just given her another opportunity to lord it over me.

Ruby pulled herself up to look me in the eye and smiled that calculating smile I’d come to know. “I’d know a cop anywhere,” she said.
* * *

I’d slipped out of the unit and into my office, a tiny closet of a room stashed between ICU and a storage closet, to work on my past-due budgets when I heard the OR transporters arrive with what I guessed was our post-op patient now out of surgery. Sighing, I clicked my computer to standby and followed Tim and the gurney into the unit.
St. Teresa’s intensive care unit is one large rectangle. Around three sides of the interior are ten, equally-sized patient cubicles sheltered by shabby blue-and-white curtains. A hallway runs outside of these rooms with doors into each room, allowing family members access without walking through the unit and getting in the way of busy staff. Along the back wall are the medication room, linen closet, clean and dirty utility rooms, and the multipurpose room we use for meetings and breaks, which held, in addition to a rickety conference table and mismatched chairs, our lockers, a small refrigerator that stays only marginally cold, a microwave with only one setting—high—and a sink often plugged up.

Paint, left over from other jobs around the hospital, covers the walls in ICU. Some are cyanotic blue, others industrial yellow, depending on what color the facilities department had remaining after they’d finished sprucing up the more visible areas of the hospital. Too many scrubbings had left the paint flaking, though, and the painters were due “any day,” a promise I’d been hearing for more than a month.

“Room ten,” I told one of the transport attendants, directing him to the only open room at the opposite end of the unit from our other trauma patient in room one. I was glad to put a little distance between the two patients and their grieving relatives. It allowed both families some privacy—what little anyone has in ICU—and made it easier for the staff. At least the nurses wouldn’t careen into each other in their hurry to get in and out of their patient’s room during those first critical days when a fresh trauma required constantly-changing care.

The transporters had moved the woman, whose name was Marian Oblansky I saw from a quick glance at the chart, onto the bed and Tim was cranking the head up to the required thirty degrees to reduce pressure in the brain when Ruby called me out.

I stepped out of the cubicle and gasped. There, with his back facing me, stood a man in an all-too-familiar military stance—ramrod posture, legs apart, and arms crossed behind him. His brown hair was cropped close, and he was just the right height, with just the right build. Then he turned around and my heart slid back down my throat. Of course it couldn’t have been Rick.

“Steve Oblansky,” the man said. “Marian Oblansky,” he swallowed and went on, “is my wife. This is her sister, Charlotte.” He nodded at the woman next to him.

He didn’t resemble Rick from the front. For one thing, his eyes were brown and wider apart. And he was older.

“How is she?” Mr. Oblansky asked, his tone respectful.

“She’s badly injured,” I said. “She hasn’t regained consciousness.”

“Is she . . .” Charlotte faltered and looked away.

“It’s too soon to know anything yet,” I said, leading them toward Mrs. Oblansky’s room as I passed Tim, who nodded an okay to go in.

At the sight of her sister’s shaved head, the woman slumped against her brother-in-law.

“Her hair . . .” he said, his voice shaking.

Charlotte turned to her brother-in-law. “It’s not her.”

“We had to cut it off for the surgery,” I said. “I’m sorry, I should have warned you.”
The shock of seeing a loved one’s shorn head, especially that of a woman, can make a patient unrecognizable even to close family members.

“It’s her, Lottie.” Then to me he said, “She had such beautiful red hair.”

“Long,” her sister said, “down her back.”
Steve took his sister-in-law’s arm and led her closer to the bed. In spite of the ventilator tube protruding from her mouth, Marian looked strangely peaceful, her body unscathed. Only the swish of air pumping through the vent and the intermittent beats of the monitors beeping her vital signs signaled the internal damage.

I didn’t tell them that the back of her head looked like a smashed pumpkin.

I left them and stepped outside to greet the man I’d seen talking to Ruby as I was taking the Oblansky family into Marian’s room.

Detective Harding flipped open his badge as if I didn’t know who he was. He’d been here on two previous occasions. “We’re here about Marian Oblansky,” Harding said, his voice lowered. He introduced his partner, a good-looking black man in his thirties.

“What can you tell me about her?” Harding unbuttoned a gray trench coat, shaking leftover rain around him. Droplets slid off his short, dark hair as he pulled a pen from inside his jacket pocket. “Is she awake? Can we talk to her?”


“I’m afraid not,” I said, steering them away from the room so we wouldn’t be overheard. “She has a serious head injury. She’s unconscious. What happened to her? How’d she get hurt?”

Harding’s partner spoke up. “She was attacked in the parking lot of First Federal on South Kingshighway, right after the bank opened, apparently.”

Harding frowned at his partner who ducked his head. “When might she wake up?”

“Her condition is guarded.”

“She might not make it?”

“We don’t know yet, but the prognosis isn’t good at this point.”

“Is her family here?” Harding asked.

“They’re in with her now.”

“Would you tell them we want to see them?”

“Sure, but I have a question. Don’t you think you should have someone guarding her room? What if the guy comes back to finish her off?”

Harding’s partner grunted. “We don’t have the manpower for that. Besides, this is probably a random assault, a robbery gone bad or something like that.”

I hesitated. I didn’t want to remind them about the previous attacks on our patients; on the other hand, I was afraid it would happen again.

“I wouldn’t worry about it,” Harding said. “I heard you’ve locked up the outside doors now so no one can get in, and things are pretty secure from this side, with everyone working in here.”

“The fire inspectors made us unlock the outside doors,” I told Harding as Steve and Charlotte came out of Mrs. Oblansky’s room, Charlotte blowing her nose and Steve wiping his eyes with the back of his hands. I introduced Detective Harding and his partner to the couple and sent a part-time volunteer to take them to the family waiting room down the hall. They all walked outside together, Steve’s arm around Charlotte’s shoulders.

There it was again, the resemblance. Charlotte leaned her head against her brother-in-law’s shoulder the same way Rick’s mother had leaned into Rick after finding out her husband had been killed in an accident.

I shook off my lingering thoughts.

“We can’t afford it,” Dick Gerling, our chief of security said after I called to ask him to send up a someone to guard Mrs. Oblansky’s room.

“That’s your job, not mine. You keep everyone but family out of her room.”

I had my orders.